North Dakota

Funding from HRSA’s Rural Communities Opioid Response Program (RCORP) program has helped several State Offices of Rural Health (SORHs) recently start—or strengthen—their work related to substance use disorder and opioid use disorder (S/OUD). Those who receive the RCORP Planning grant have a year to create or strengthen a consortium focused on SUD/OUD. (HRSA currently offers an RCORP Implementation grant that some SORH have received as well.)

The new “SORH Response to the SUD Crisis” issue brief provides a scan of what SORH are doing to engage in the recent substance use disorder (SUD) and opioid use disorder (OUD) initiatives in their state.

For example, the South Carolina Office of Rural Health (SCORH) had never focused on S/OUD activities prior to receiving the RCORP Planning grant, according to Lindsey Kilgo, SCORH Director of Network Development. For them the grant was “about how we can understand what’s going on in the state,” Kilgo said. “There’s been a lot of information gathering, a lot of consortium and office conversations, a lot of convening and bringing folks together.”

Forging Stronger Partnerships

While creating their consortium, the Virginia SORH (VA SORH) discovered new partners. “There are additional people at the table who might not have been there because of the consortium,” said Heather Anderson, VA SORH Director. “We added to the conversation and got community health centers and other folks that maybe weren’t involved before. We have stronger partnerships in the region.”

Anderson continued, “Because of our experience with the planning grant, another agency was willing to run with the implementation grant. So we said, ‘Go for it. You’re local, you know all the people. We will support you any way we can, give you technical assistance, and help you convene people.’”

For the Michigan Center for Rural Health (MCRH), the planning grant “has allowed us to really bring everybody to the table and wrap our arms around the importance of the challenges in those counties we are working in,” said Crystal Barter, MCRH Director of Performance Improvement. “I think everyone has really bought into it, whereas before everyone was working in their own silo. And now we are working as a consortium and starting to leverage the resources each organization has.”

Hanneke Van Dyke, former SORH Coordinator at the Texas SORH, also talked about the importance of community outreach. “It was important to use relationships we already had and having an openness to expanding relationships to new project areas,” Van Dyke said. “In both of our (RCORP) project areas, community advisory councils—made up of community members and community leaders who are there for every step of the process—have been central. Making sure we built in a few back routes tied back to the community was very important for us.”

No Prior Expertise Needed

When asked what skills are needed for SORHs to engage with S/OUD work, Kilgo replied, “Having the determination to make things better and to make change—and then not being afraid to ask questions, in an effort to build knowledge, partnerships, and relationships.” Kilgo added, “For folks who work in this particular realm, it requires a level of passion and commitment. And when you have that shared passion and commitment, the relationship and trust come fairly easily. We all have a common vision and common theme. We’re moving forward together in a positive manner.”

The ability to seek out experts was also key for Van Dyke. “None of us on staff had worked on an S/OUD issues or had any particular training or experience with it,” she said. “As project coordinator, I’ve taken it on to educate myself through reading and talking with experts. I’m not an expert but I’m pretty comfortable now, knowing who to go to to get the right information.”

Although the North Dakota Center for Rural Health (NDCRH) has been involved with S/OUD activities for the state for a few years, they had no broad expertise in their office when they started their RCORP work, said Lynette Dickson, NDCRH Director. “Our knowledge has grown and continues to grow,” Dickson said.

“Even if you are not an expert in the field you can still have an impact in this arena,” Dickson explained. “Because what we (SORHs) do is convene people, and reach out and find the resources. You can have more confidence that you can have an active role in this—you can convene and connect like we do with anything else.”

How did you get to where you are now?
I have a master’s degree in Advanced Public Health Nursing from the University of North Dakota and a bachelor’s degree in nursing from Minot State University. Before joining the Center for Rural Health in 2008, I was a Health Care QI Project Coordinator for our state’s QIO and was an ICU registered nurse. I currently coordinate activities of the ND Flex Program. I have led the ND CAH Quality Network(Network) in a number of quality and patient safety initiatives and serve as a liaison to statewide stakeholders, facilitating the exchange of information and network development.

What are 3 great things about rural health in your state?
1. The Network serves as a platform for CAHs to share best practices, policies and processes to improve quality improvement and safer patient care.

2. ND CAHs have strength in numbers! 100% (36/36) participate in the Network to share ideas or topics. Through collaborative work of the Network, ND Flex Program, SORH and other stakeholders, a statewide stroke system of care was developed.

3. The ND Flex Program provides an opportunity for CAH staff to learn from their peers.The Rural Healthcare Peer Exchange Program provides travel support for individuals or small groups to meet with similar entities from other areas of the state and share information and successful approaches to improving quality and access to healthcare services.

What is the most important thing you are working on right now?
The Network recently completed an update to a CMS Conditions of Participation CAH regulations checklist that has been created using Flex funding. The checklist highlights conditions that require policies and processes in place to meet the regulation. The technical assistance provided has been identified by our CAHs as a top priority area. In addition to the checklist, the Network hosts quarterly webinar meetings, which all ND CAHs join with their teams to discuss their state survey experience, and deficiencies, along with their plans of correction.

What are you doing to ensure you continue to grow and develop as a leader?
I stay engaged in rural topics and always look for opportunities to learn from what others are doing. I regularly attend meetings offered by our project officers and national technical assistance center, attend education opportunities, volunteer to be on committees (a good way to meet other state programs), and read as much as I can. Engage other state programs and ask how they had success on something and learn from them.

What do you do when you are not working?
Make memories with my husband of 33 years and 2 daughters. We also have 2 little dogs that I groom and walk. I am a movie-goer, enjoy reading, and attend Aqua Dance and Aqua Exercise 3 days a week.

How did you get to where you are now?
I had an attraction to the general idea of rural; it wasn’t my academic background. I grew up on a durum wheat farm in rural North Dakota. As a farm boy, rural was something I could relate to. I’m now in my 31st year at the Center for Rural Health. I started in 1985 out of grad school as a program assistant and then became a program coordinator. When the Center got their first rural health research center grant, I became a policy analyst. I was named Associate Director in 1991 and remained in that position until becoming Deputy Director in 2010.

What inspires/excites you most about working at the Center for Rural Health?
It’s the same thing in 2016 as it was in 1985 – an opportunity to try to make a difference. I want to be intellectually challenged, take what I learn and turn it around to help other people…help the people I grew up with. It makes a difference if you’re working in the state you grew up in because you truly understand the culture, norms, values, people and have a sense of the topography.

What is the most important thing you are working on right now?
I’m working with our Flex Program on a new round of Community Health Needs Assessments. I started 31 years ago by getting in a car in my first week and going to a small town to do interviews for recruitment and retention. What I enjoy more than anything is going to a rural community and doing something that directly benefits that town. I want to help them think through where they are now and where they want to go.

What is one characteristic that you believe every rural health leader should possess?
Flexibility. People who don’t understand rural health think of it as being simple, especially because of small areas and populations. They think it can’t be as complicated as urban issues. Rural has complex issues because of a small population spread out over a large area with unique access issues. SORHs have to know a little bit about a lot of things. Anybody interested in rural health should definitely spend part of their career as a generalist. Learn how to do a lot of different things. In the process you will figure out what stimulates you and what you’re good at. The more different things you can do, the more value you are to an organization.

What are you doing to ensure you continue to grow and develop as a rural health leader?
I operate from assumption that I don’t know everything. I go directly to rural communities to learn, attend conferences and talk with colleagues. I like to ask people what they are doing and learning. I want them to share it with me to keep me fresh. Never allow yourself to quit learning!

The Rural Collaborative Opportunities for Occupational Learning in Health Scrubs Program, supported by the Center for Rural Health (CRH) and the North Dakota Area Health Education Centers, provides unique, interactive opportunities for rural North Dakota students to learn about health care careers from professionals in the field. Based on programs offered by the South Dakota Healthcare Workforce Center, the goal of the program is to increase students’ knowledge and interest in health careers available in rural North Dakota.

“The idea behind the program is that if students understand at an early age the wide range of options in health careers, they are more likely to consider a health care career,” said Kylie Nissen, Senior Project Coordinator, CRH. “If students are aware of career opportunities in their hometown, and the need for those services in rural areas, they may return after completing higher education.”

Scrubs Camps are held in rural North Dakota communities to introduce students in grades 5-12 to the wide-ranging field of health care. Not to be confused with careers fairs, these camps feature interactive activities led by local health care professionals, offering students the chance to learn firsthand about specific health careers and what it is like to work in a rural North Dakota community.

Building upon the Scrubs Camp concept, the CRH also offers the Scrubs Academy, a four day, three-night summer camp held at the University of North Dakota. Geared toward middle school students, the Scrubs Academy introduces students to a higher education environment and strengthens their skill sets with a variety of hands-on activities.

The community collaboration and interactive opportunities provided truly make the Scrubs Program stand out. Rural North Dakota K-12 schools and health care facilities are eligible to apply for grant funding to support the Scrubs Program in their community. Applicants are required to actively partner with local K-12 school systems, local health care facilities, local economic or job development authorities or similar entities. These community partners then work together to put on the camps for local students.

In order to keep enhancing the program, evaluations are completed by students, presenters, and staff at each Camp and Academy. Improvements are made based on what’s reflected in the evaluations. Emails are sent to the students and their parents every two years until the students are out of high school to determine the students’ career intent and if the Scrubs Program influenced their decision in pursuing a health-related career. In addition, the CRH is currently working on gaining access to a service that will allow them to see which college program students pursue.

“One student that attended a Scrubs Camp 6 years ago didn’t have a career goal in mind when attending, but through the camp discovered that she really wanted to be a nurse. She was accepted into her college nursing program last year and attributes her career decision to the Scrubs Camp she attended,” said Nissen.

Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger at ashleym@nosorh.org to set up a short email or phone interview in which you can tell your story.

North Dakota is one of the larger state offices. What advice can youshare on effectively managing a team?

My advice on how to effectively manage a team is to build the team with individuals who are smarter than you. I am blessed to be surrounded by individuals who are not only intelligent, creative and dedicated but more importantly positive thinkers and real team players. They possess the self-confidence to not only share their own ideas and thoughts but also sincerely engage and learn from others. That makes it much easier to effectively manage the team. As my responsibilities have expanded I would say trust is the key word. I trust that the team members are capable and accountable; will keep me informed and will ask questions as needed. The trust should go both ways. I hope they trust that I will support them in their work; provide constructive guidance and direction and view mistakes as learning opportunities. I try to (gently) push them beyond their comfort zone with the intent of helping them to learn, gain confidence and recognize their potential. I learned that from Dr. Mary Wakefield, our director for a number of years. When I was very new to the CRH, she often asked me, and others, to take on things way ‘outside our comfort zone’. At the time, it was stressful; however, many of those opportunities turned in to areas of comfort. Finally, in working with a team it is vital to not take ourselves too seriously. We should laugh and have fun – no matter the deadlines and workload.

One thing that sets North Dakota apart from many other states is itsNative American population. Tell us about your work with the tribal communities.​

The Center for Rural Health (CRH) has three notable national programs focusing on Native American population. The oldest of which is The National Resource Center on Native American Aging, funded by the DHHS, Administration on Community Living(ACL), formerly Administration on Aging. This program has been in existence for over 20 years and focuses on conducting Native Elder health and social needs assessments with tribes/villages and homesteads around the country, to include Alaska and Hawaii. To date, 70,000 completed surveys have been completed representing up to 342 of the federally recognized tribes. The results of the assessments are used at the local level to apply for the Title VI nutrition and caregiving grants, as well as to plan and develop other programs to address issues impacting Native Elders.

Two additional national programs, newer to the CRH, are the National Indigenous Elder Justice Initiative (NIEJI) funded by ACL; created to provide research, education, and training for the identification and prevention of elder abuse in Indigenous communities; and the third national program is Seven Generations Center for Excellence in Native Behavioral Health (SGCoE), funded by HRSA, that supports Native Americans working toward becoming, or currently serving as, mental health professionals. The success and strength of these programs is attributed to having experienced and dedicated staffs such as Jacque Gray PhD and Paul Carter PhD who are both registered tribal members which gives them a natural advantage of knowing the population and cultural practices that facilitate the development of trust relationships within the Native American communities. They, along with others within our office and around the state, use the programmatic focus of these three national programs to cross-mentor and train a number of Native American undergraduate and graduate students to develop future workforce and leadership to serve tribal communities.

Kylie Nissen is the Senior Program Coordinator at the North Dakota Center for Rural Health (CRH) and is the Executive Director of the ND Rural Health Association (NDRHA). In addition, she serves on the NOSORH Communications Committee.

How does your work with the NDRHA feed your work with the CRH and vice versa?

Through my work with the State Office, I also serve as the NDRHA Executive Director. The NDRHA has a contract with the CRH to provide executive director, graphics, and web services. So much of the work I do for one feeds into the other. It has allowed for opportunities to collaborate on numerous occasions. For instance, while the CRH is not able to advocate, the NDRHA does
have this ability. During the legislative sessions the CRH (education) and the NDRHA (advocacy) work hand-in-hand to provide optimum outcomes for rural health in North Dakota. NDRHA and the CRH have also been major partners and promoters of National Rural Health Day within North Dakota.

My role with NDRHA is to facilitate the conversations between members and help them decide what they are going to work together to address and how they will execute it. By having a group of people that are not just hospitals, not just pharmacists, not just nurses, but a mixture of numerous areas involved in rural healthcare both directly and indirectly, all rallied around a common cause, it makes a big impact. A big part I play is as a cheerleader. It is my job to keep all of the volunteers that the NDRHA is made up of motivated and on task, getting things done when it isn’t their primary job.

What’s the best part of your job?

The best part of my job is the people–within the Center, the state and the nation. Nearly everyone that I encounter in this job has a passion for what they do. It is tremendously motivating when you are surrounded by this type of people.

In addition to your work at the CRH and with NOSORH and NDRHA, you show horses in your spare time. How do you juggle it all?

Rural is where my heart is and I have always had a passion for health care. In addition to my full-time job with CRH, I also serve as the Executive Director of the North Dakota Chapter of the American Academy of Pediatrics, which, in a rural state like North Dakota, has a big rural focus. I’m also working on my Masters in Public Health with a rural focus. Juggling it all can get a little
tough at times, but with the support of an amazing husband and family, it all works out. Something I always worry about is being able to spend time with my daughter–thankfully she loves horses too, so we spend every weekend together showing horses and barrel racing.